Imparting guideline knowledge to doctors constitutes merely one of the building blocks for the practical therapeutic use of guideline knowledge. The path to clinical competence leads from the mere knowledge of facts to explaining the reasons/causes underlying those facts to the demonstration of skills to their independent application (1). The authors’ conclusion—that physicians’ knowledge of guidelines does not in itself lead to better guideline implementation—is self-ev dent rather than surprising from a didactic perspective.
The authors conclude that doctors’ therapeutic decisions are shaped to a lesser extent by medical data and to a greater extent by organizational routines, financial framework conditions, and patient related aspects. This conclusion reflects important characteristics of general practitioners’ work: including patients’ preferences and collaborating specialist physicians into identifying a joint therapeutic decision (2). It cannot necessarily be assumed that these factors are equally distributed in the study practices of doctors with adequate or inadequate knowledge of guidelines. Regrettably, neither was the perspective of the patients elicited with regard to the presented guideline implementation nor were data collected on hard end points with relevance for patients (mortality, hospitalization).
To investigate the total process of different strategies for guideline implementation up to the effect on patients, cluster-randomized studies are appropriate. The different implementation strategies are randomly allocated to the practices, and the treatment of patients in the comparator groups needs to be standardized. Such studies exist for the treatment and secondary prophylaxis of cardiovascular disorders; there is a sufficiently large number of them and they are of sufficiently high quality (3). Before testing new implementation aids, existing knowledge should be systematically summarized and discussed, in manner that is appropriate to the target group and the indication.
Dr. rer. nat. Susanne Unverzagt
Dr. med. Andreas Klement
Institut für Medizinische Epidemiologie, Biometrie und Informatik, Halle, Germany
Conflict of interest statement
The authors declare that no conflict of interest exists.
|1.||Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990; 65: 63–7. MEDLINE|
|2.||Van Royen P, Beyer M, Chevallier P, et al.: The research agenda for general practice/family medicine and primary health care in Europe. Part 3. Results: person centred care, comprehensive and holistic approach. Eur J Gen Pract 2010; 16: 113–9. MEDLINE|
|3.||Peters-Klimm F, Müller-Tasch T, Remppis A, Szecsenyi J, Schellberg D: Improved guideline adherence to pharmacotherapy of chronic systolic heart failure in general practice – results from a cluster-randomized controlled trial of implementation of a clinical practice guideline. J Eval Clin Pract 2008; 14: 823–9. MEDLINE|
|4.||Karbach U, Schubert I, Hagemeister J, Ernstmann N, Pfaff H, Höpp HW: Physicians’ knowledge of and compliance with guidelines: an exploratory study in cardiovascular diseases. Dtsch Arztebl Int 2011; 108(5): 61–9. VOLLTEXT|